1
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Ashoor IF, Engen RM, Puliyanda D, Hayde N, Peterson CG, Zahr RS, Solomon S, Kallash M, Garro R, Jain A, Harshman LA, McEwen ST, Mansuri A, Gregoski MJ, Twombley KE. Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium. Pediatr Transplant 2024; 28:e14734. [PMID: 38602171 PMCID: PMC11013566 DOI: 10.1111/petr.14734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/22/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. There is a paucity of large-scale pediatric-specific data regarding AMR treatment outcomes. METHODS Data were obtained from 14 centers within the Pediatric Nephrology Research Consortium. Kidney transplant recipients aged 1-18 years at transplant with biopsy-proven AMR between 2009 and 2019 and at least 12 months of follow-up were included. The primary outcome was graft failure or an eGFR <20 mL/min/1.73 m2 at 12 months following AMR treatment. AMR treatment choice, histopathology, and DSA class were also examined. RESULTS We reviewed 123 AMR episodes. Median age at diagnosis was 15 years at a median 22 months post-transplant. The primary outcome developed in 27.6%. eGFR <30 m/min/1.73 m2 at AMR diagnosis was associated with a 5.6-fold higher risk of reaching the composite outcome. There were no significant differences in outcome by treatment modality. Histopathology scores and DSA class at time of AMR diagnosis were not significantly associated with the primary outcome. CONCLUSIONS In this large cohort of pediatric kidney transplant recipients with AMR, nearly one-third of patients experienced graft failure or significant graft dysfunction within 12 months of diagnosis. Poor graft function at time of diagnosis was associated with higher odds of graft failure.
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Affiliation(s)
- Isa F Ashoor
- Department of Pediatrics, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Dechu Puliyanda
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nicole Hayde
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Caitlin G Peterson
- Division of Pediatric Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Rima S Zahr
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Sonia Solomon
- Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Boston Children's Health Physicians, Valhalla, New York, USA
| | - Mahmoud Kallash
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rouba Garro
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Amrish Jain
- Department of Pediatrics, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Lyndsay A Harshman
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Scott T McEwen
- Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Asifhusen Mansuri
- Department of Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, Georgia, USA
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine E Twombley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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2
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DiLeo MJ, Miggins JJ, Brewer ED, Galván NTN, Rana A. A novel risk score for predicting prolonged length of stay following pediatric kidney transplant. Pediatr Nephrol 2023; 38:4187-4196. [PMID: 37434028 DOI: 10.1007/s00467-023-06066-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Kidney transplants (KT) are accepted as the kidney replacement therapy of choice for children with kidney failure. The surgery itself may be more difficult especially in small children, and often leads to significant hospital stays. There is little research on predicting prolonged length of stay (LOS) in children. We aim to examine the factors associated with prolonged LOS following pediatric KT to help clinicians make informed decisions, better counsel families, and potentially reduce preventable causes of prolonged stay. METHODS We retrospectively analyzed the United Network for Organ Sharing database for all KT recipients less than 18 years old between January 2014 and July 2022 (n = 3693). Donor and recipient factors were tested in univariate and multivariate logistic analysis using stepwise elimination of non-significant factors to create a final regression model predicting LOS longer than 14 days. Values were assigned to significant factors to create risk scores for each individual patient. RESULTS In the final model, only primary diagnosis of focal segmental glomerulosclerosis, dialysis prior to KT, geographic region, and recipient weight prior to KT were significant predictors of LOS longer than 14 days. The C-statistic of the model is 0.7308. The C-statistic of the risk score is 0.7221. CONCLUSIONS Knowledge of the risk factors affecting prolonged LOS following pediatric KT can help identify patients at risk of increased resource use and potential hospital-acquired complications. Using our index, we identified some of these specific risk factors and created a risk score that can stratify pediatric recipients into low, medium, or high risk groups. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Michael J DiLeo
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA.
| | - John J Miggins
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Eileen D Brewer
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - N Thao N Galván
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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3
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Levy R, Kopp JB, Franceschini N. Genetics of Focal Segmental Glomerulosclerosis in African American Children. Am J Kidney Dis 2023; 81:627-628. [PMID: 37074247 DOI: 10.1053/j.ajkd.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/17/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Rebecca Levy
- School of Medicine, University of Rochester, Rochester, New York
| | - Jeffrey B Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland
| | - Nora Franceschini
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.
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4
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Charnaya O, Zeiser L, Yisar D, Goldberg A, Segev DL, Massie A, Garonzik-Wang J, Verghese P. The unfinished journey toward transplant equity: an analysis of racial/ethnic disparities for children after the implementation of the Kidney Allocation System in 2014. Pediatr Nephrol 2023; 38:1275-1289. [PMID: 35816202 PMCID: PMC10848995 DOI: 10.1007/s00467-022-05676-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Disparities in pediatric kidney transplantation (KT) result in reduced access and worse outcomes for minority children. We assessed the impact of recent systems changes on these disparities. METHODS This is a retrospective cohort study of pediatric patients utilizing data from the US Renal Data System (n = 7547) and Scientific Registry of Transplant Recipients (n = 6567 waitlisted and n = 6848 transplanted patients). We compared access to transplantation, time to deceased donor kidney transplant (DDKT), and allograft failure (ACGF) in the 5 years preceding implementation of the Kidney Allocation System (KAS) to the 5 years post-KAS implementation 2010-2014 vs. 2015-2019, respectively. RESULTS Compared to the pre-KAS era, post-KAS candidates were more likely to be pre-emptively listed (26.8% vs. 38.1%, p < 0.001), pre-emptively transplanted (23.8% vs. 28.0%, p < 0.001), and less likely to have private insurance (35.6% vs. 32.3%, p = 0.01), but these were not uniform across racial groups. Compared to white children, Black and Hispanic children had a lower likelihood of transplant listing within 2 years of first dialysis service (aHR 0.590.670.76 and 0.730.820.92, respectively) in the post-KAS era. Time to DDKT was comparable across all racial groups in the post-KAS era. Compared to white children, Black DDKT recipients have more 5-year ACGF (aHR 1.001.432.06 p = 0.05) while there was no difference in 3- or 5-year ACGF among LDKT recipients. CONCLUSIONS After KAS implementation, there is equity in time to DDKT. Pre-KAS increased hazard of ACGF among Black children has decreased in the post-KAS era; however, persistent disparities exist in time to transplant listing among Black and Hispanic children when compared to white children. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Laura Zeiser
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Dolev Yisar
- Medical School for International Health, Ben-Gurion University of the Negev, Be-er Sheva, Israel
| | - Aviva Goldberg
- Department of Pediatric Nephrology, University of Manitoba, Winnipeg, Canada
| | - Dorry L Segev
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Scientific Registry of Transplant Recipients, Minneapolis, MN, USA
| | - Allan Massie
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Jacqueline Garonzik-Wang
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Priya Verghese
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL, USA
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5
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Rea KE, West KB, Dorste A, Christofferson ES, Lefkowitz D, Mudd E, Schneider L, Smith C, Triplett KN, McKenna K. A systematic review of social determinants of health in pediatric organ transplant outcomes. Pediatr Transplant 2023; 27:e14418. [PMID: 36321186 DOI: 10.1111/petr.14418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods. METHODS Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases. RESULTS Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent. CONCLUSION This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Kara B West
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Dorste
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Debra Lefkowitz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Mudd
- Cleveland Clinic Children's, Center for Pediatric Behavioral Health, Wilmington, North Carolina, USA
| | - Lauren Schneider
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Courtney Smith
- Norton Children's, University of Louisville, Louisville, Kentucky, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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6
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Influence of Donor Race and Donor-recipient Race-matching on Pediatric Kidney Transplant Outcomes. Transplant Direct 2022; 8:e1324. [PMID: 35557992 PMCID: PMC9088235 DOI: 10.1097/txd.0000000000001324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 11/26/2022] Open
Abstract
Existing literature has demonstrated the significant relationship between race and kidney transplant outcomes; however, there are conflicting and limited data on the influence of donor race or donor-recipient race-matching on pediatric kidney transplant outcomes.
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7
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Mai K, Singer P, Fahmy AE, Teperman LW, Molmenti EP, Grodstein EI, Castellanos L, Sethna CB. Kidney transplant outcomes in children and adolescents with systemic lupus erythematosus. Pediatr Transplant 2022; 26:e14178. [PMID: 34687584 DOI: 10.1111/petr.14178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/17/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Literature supports equivalent kidney transplant outcomes in adults with systemic lupus erythematosus (SLE) compared with those without SLE. However, there are conflicting and scant data on kidney transplant outcomes, as well as controversy over optimal timing of transplantation, in children and adolescents with SLE. METHODS Analysis included kidney-only transplant recipients aged 2-21 years from 2000 to 2017 enrolled in the Organ Procurement and Transplant Network (OPTN). The relationship between diagnosis (SLE n = 457, non-SLE glomerular disease n = 4492, and non-SLE non-glomerular disease n = 5605) and transplant outcomes was evaluated. The association between dialysis time and outcomes was analyzed in the SLE group only. RESULTS In adjusted models, SLE had higher mortality compared with non-SLE glomerular recipients (HR 1.24 CI 1.07-1.44) and non-glomerular recipients (HR 1.42 CI 1.20-1.70). SLE was associated with higher graft failure compared with non-SLE glomerular (HR 1.42 CI 1.20-1.69) and non-glomerular disease (HR 1.67 CI 1.22-2.28). SLE had a higher risk of acute rejection at 1 year compared with non-glomerular disease (HR 1.39 CI 1.03-1.88). There was a decreased risk of delayed graft function compared with non-SLE glomerular disease (HR 0.54, CI 0.36-0.82). There were no significant associations between dialysis time and transplant outcomes in the SLE group. CONCLUSION SLE in children and adolescents is associated with worse patient and graft survival compared with non-SLE diagnoses. Outcomes in children and adolescents with SLE are not associated with dialysis time. Further studies are needed to assess implications of potential earlier transplantation and shorter time on dialysis prior to transplantation.
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Affiliation(s)
- Katherine Mai
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA
| | - Pamela Singer
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Ahmed E Fahmy
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Lewis W Teperman
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Ernesto P Molmenti
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Elliot I Grodstein
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Laura Castellanos
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Christine B Sethna
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
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8
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Kurian SM, Spierling Bagsic SR, Case J, Barrick BL, Schaffer R, Rice JC, Marsh CL. UNOS/OPTN Data-guided Assessment of Focal Segmental Glomerulosclerosis After Kidney Transplantation and Evaluation of Immunosuppressive Protocols in a Steroid-free Center. Transplant Direct 2021; 7:e738. [PMID: 34386576 PMCID: PMC8354624 DOI: 10.1097/txd.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/14/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) is a common recurrent glomerulopathy associated with graft loss and patient survival after kidney transplantation (KT). However, its natural history, clinical predictors, and treatment response are still poorly understood. Steroid withdrawal regimens in KT have been associated with improvements in cardiovascular risk and patient outcomes. The Scripps Center for Organ Transplantation (SCOT) uses a rapid low-dose steroid withdrawal immunosuppression (IS) protocol for KT maintenance. METHODS We assessed the impact of our protocol on FSGS disease recurrence over a 10-y period to reassess our steroid and IS protocols and to evaluate if our patient outcomes diverge from published data. We compared 4 groups: steroids always, steroid free, steroid switch on, and steroid weaned off. We used IS and induction-matched retrospective data from United Network for Organ Sharing (UNOS) to investigate patient and graft survival for FSGS at SCOT. RESULTS Our analysis results differ from earlier studies showing that FSGS was associated with a higher risk of graft loss, perhaps because of selection of a UNOS data set filtered to match the SCOT IS protocol for making direct comparisons. Overall outcomes of graft failure and recipient death did not differ between SCOT patients and steroid-free transplant patient data from the UNOS data for FSGS. SCOT recurrence rate for FSGS was 7.5%, which was lower than in most published single-center studies. CONCLUSIONS Based on our results, we believe that it is safe to continue the steroid avoidance protocols at SCOT and the steroid-free protocol may not be detrimental when the adverse effects and toxicities associated with steroid use are considered.
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Affiliation(s)
- Sunil M. Kurian
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
| | | | - Jamie Case
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
| | - Bethany L. Barrick
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
| | - Randolph Schaffer
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
| | - James C. Rice
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
| | - Christopher L. Marsh
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
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9
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A focus on the association of Apol1 with kidney disease in children. Pediatr Nephrol 2021; 36:777-788. [PMID: 32253519 DOI: 10.1007/s00467-020-04553-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/14/2022]
Abstract
Individuals of African origin have an increased risk of developing various progressive chronic kidney diseases (CKD). This risk has been attributed to genetic variants (G1, G2) in apolipoprotein-L1 (APOL1) gene. In the pediatric population, especially in children affected by sickle cell disease (SCD), by human immunodeficiency virus (HIV), or with various glomerular diseases, APOL1 risk variants have been associated with the development of hypertension, albuminuria, and more rapid decline of kidney function. The present review focuses on existing APOL1-related epidemiological data in children with CKD. It also includes data from studies addressing racial disparities in CKD, the APOL1-related innate immunity, and the relationship between APOL1 and CKD and pathogenic pathways mediating APOL1-related kidney injury.
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10
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Uffing A, Pérez-Sáez MJ, Mazzali M, Manfro RC, Bauer AC, de Sottomaior Drumond F, O'Shaughnessy MM, Cheng XS, Chin KK, Ventura CG, Agena F, David-Neto E, Mansur JB, Kirsztajn GM, Tedesco-Silva H, Neto GMV, Arias-Cabrales C, Buxeda A, Bugnazet M, Jouve T, Malvezzi P, Akalin E, Alani O, Agrawal N, La Manna G, Comai G, Bini C, Muhsin SA, Riella MC, Hokazono SR, Farouk SS, Haverly M, Mothi SS, Berger SP, Cravedi P, Riella LV. Recurrence of FSGS after Kidney Transplantation in Adults. Clin J Am Soc Nephrol 2020; 15:247-256. [PMID: 31974287 PMCID: PMC7015092 DOI: 10.2215/cjn.08970719] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES FSGS recurrence after kidney transplantation is a major risk factor for graft loss. However, the natural history, clinical predictors, and response to treatment remain unclear because of small sample sizes and poor generalizability of single-center studies, and disease misclassification in registry-based studies. We therefore aimed to determine the incidence, predictors, and treatment response of recurrent FSGS in a large cohort of kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Post-Transplant Glomerular Disease (TANGO) project is an observational, multicenter, international cohort study that aims to investigate glomerular disease recurrence post-transplantation. Transplant recipients were screened for the diagnosis of idiopathic FSGS between 2005 and 2015 and details were recorded about the transplant, clinical outcomes, treatments, and other risk factors. RESULTS Among 11,742 kidney transplant recipients screened for FSGS, 176 had a diagnosis of idiopathic FSGS and were included. FSGS recurred in 57 patients (32%; 95% confidence interval [95% CI], 25% to 39%) and 39% of them lost their graft over a median of 5 (interquartile range, 3.0-8.1) years. Multivariable Cox regression revealed a higher risk for recurrence with older age at native kidney disease onset (hazard ratio [HR], 1.37 per decade; 95% CI, 1.09 to 1.56). Other predictors were white race (HR, 2.14; 95% CI, 1.08 to 4.22), body mass index at transplant (HR, 0.89 per kg/m2; 95% CI, 0.83 to 0.95), and native kidney nephrectomies (HR, 2.76; 95% CI, 1.16 to 6.57). Plasmapheresis and rituximab were the most frequent treatments (81%). Partial or complete remission occurred in 57% of patients and was associated with better graft survival. CONCLUSIONS Idiopathic FSGS recurs post-transplant in one third of cases and is associated with a five-fold higher risk of graft loss. Response to treatment is associated with significantly better outcomes but is achieved in only half of the cases.
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Affiliation(s)
- Audrey Uffing
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria José Pérez-Sáez
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Marilda Mazzali
- Division of Nephrology, School of Medical Sciences, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Roberto C Manfro
- Division of Nephrology, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Andrea Carla Bauer
- Division of Nephrology, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Michelle M O'Shaughnessy
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kuo-Kai Chin
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Carlucci G Ventura
- Kidney Transplant Service, Hospital das Clinicas-University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Fabiana Agena
- Kidney Transplant Service, Hospital das Clinicas-University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Elias David-Neto
- Kidney Transplant Service, Hospital das Clinicas-University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Juliana B Mansur
- Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Helio Tedesco-Silva
- Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Gilberto M V Neto
- Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Anna Buxeda
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Mathilde Bugnazet
- Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France
| | - Thomas Jouve
- Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France
| | - Enver Akalin
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Omar Alani
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Nikhil Agrawal
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Claudia Bini
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Saif A Muhsin
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Samira S Farouk
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Meredith Haverly
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suraj Sarvode Mothi
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stefan P Berger
- Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leonardo V Riella
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts;
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11
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Moxey-Mims M. Kidney Disease in African American Children: Biological and Nonbiological Disparities. Am J Kidney Dis 2019; 72:S17-S21. [PMID: 30343717 DOI: 10.1053/j.ajkd.2018.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 06/25/2018] [Indexed: 11/11/2022]
Abstract
Pediatric-onset chronic kidney disease (CKD) is as relevant to adults as it is to children. Congenital anomalies of the kidney and urinary tract may have a significant impact on health from birth or during childhood or may not manifest until adulthood. Many acquired kidney diseases start to appear in late childhood and adolescence. The propensity for more rapid progression of CKD to end-stage kidney disease in adults of African ancestry, as well as disparities in access to kidney transplantation and allograft longevity, have been well documented for decades. Similar disparate patterns are seen in children, and we now know that there are a range of biological and nonbiological risk factors for the development and progression of CKD in people of African descent that are pertinent to CKD in children. In some cases, it is unclear whether there are effective potential interventions, whereas in other situations, there are opportunities to improve outcomes.
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Affiliation(s)
- Marva Moxey-Mims
- Pediatrics, The George Washington University School of Medicine and Health Sciences; and Division of Nephrology, Children's National Health System, Washington, DC.
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12
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Koh LJ, Martz K, Blydt-Hansen TD. Risk factors associated with allograft failure in pediatric kidney transplant recipients with focal segmental glomerulosclerosis. Pediatr Transplant 2019; 23:e13469. [PMID: 31169337 DOI: 10.1111/petr.13469] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/08/2019] [Accepted: 02/11/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND With improved outcomes for children transplanted with FSGS since previous NAPRTCS registry reports, this study re-evaluates the association of living donation, immunosuppression, and DGF on graft survival. SETTING Patients transplanted between 2002 and 2016, comparing FSGS diagnosis vs other glomerular diseases. METHODS Primary outcomes were allograft survival and FSGS recurrent-free graft survival. Potential risk factors were obtained at the time of transplant and up to 30 days post-transplantation. Analysis considered a priori that DGF may be a proxy for severe FSGS recurrence. Multivariable survival models for outcome were tested for sensitivity without/with DGF to determine features independent of recurrence. RESULTS From the larger cohort of 3010 patients, 5-year graft survival in children with FSGS (n = 455) was worse (74.3%) compared with other glomerular diseases (87.1%, n = 690) (HR 1.45, P = 0.033). Modeling all glomerular diseases, survival risk was associated with deceased donor (HR 1.83, P = 0.002), re-transplantation (HR 1.58, P = 0.013), and recipient age (HR 1.06/y, P = 0.002). The living donor advantage was not confirmed in a FSGS model (HR 1.51 for deceased, P = 0.12). DGF was highly associated with graft failure (HR 4.39, P < 0.001) and independent of re-transplant history but not FSGS diagnosis. Induction agents or primary immunosuppression choices were not associated with survival. CONCLUSION Graft survival rates have improved since the previous report. Living donor did not predict graft failure, but there remains no survival advantage. DGF was the primary independent predictor for graft loss secondary to FSGS recurrence, consistent with DGF being a proxy for severe recurrent disease.
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Affiliation(s)
- Lee Jin Koh
- Paediatric Nephrology, National University Hospital System, Singapore, Singapore.,Pediatric Nephrology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Karen Martz
- EMMES Corporation, Rockville, Maryland, United States of America
| | - Tom David Blydt-Hansen
- Multi Organ Transplant Program, BC Children's Hospital, Vancouver, British Columbia, Canada
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13
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Chen J, Liverman R, Garro R, Jernigan S, Travers C, Winterberg PD. Acute cellular rejection treatment outcomes stratified by Banff grade in pediatric kidney transplant. Pediatr Transplant 2019; 23:e13334. [PMID: 30537179 DOI: 10.1111/petr.13334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 10/22/2018] [Accepted: 11/04/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION There are limited data to guide optimal treatment strategies for acute cellular rejection (ACR) based on Banff grade for pediatric kidney transplant recipients. This report reviews a large pediatric transplant center's experience with ACR. MATERIALS AND METHODS A retrospective analysis of pediatric kidney transplant recipients at our center from 2007 to 2014 was performed. Primary outcomes were incidence of graft failure and graft function one year following ACR based on Banff grade and treatment received. RESULTS A total of 204 patients were reviewed, of which 65 received rejection treatment with either an oral steroid cycle (n = 16), intravenous steroid pulse (n = 28), or anti-thymocyte globulin (rATG, n = 21). Overall, patients received rATG for treatment of more severe rejection associated with impaired graft function and as a group experienced statistically significant improvements in eGFR over the year following treatment, though most did not regain baseline graft function. DISCUSSION Our data suggest that rATG is partially effective in treating ACR, but our study was underpowered to determine the effect of different treatments based on Banff grade. Since there is limited literature to guide clinical treatment of ACR in children, large transplant centers should collaborate to evaluate outcomes and establish evidence-based practice.
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Affiliation(s)
- Justin Chen
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pharmacy, NewYork-Presbyterian Columbia University Medical Center, New York, New York
| | - Rochelle Liverman
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Rouba Garro
- Pediatric Nephrology at Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Stephanie Jernigan
- Pediatric Nephrology at Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Pediatric Biostatistics Core, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Pamela D Winterberg
- Pediatric Nephrology at Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University, Atlanta, Georgia
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14
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Uffing A, Pérez-Sáez MJ, La Manna G, Comai G, Fischman C, Farouk S, Manfro RC, Bauer AC, Lichtenfels B, Mansur JB, Tedesco-Silva H, Kirsztajn GM, Manonelles A, Bestard O, Riella MC, Hokazono SR, Arias-Cabrales C, David-Neto E, Ventura CG, Akalin E, Mohammed O, Khankin EV, Safa K, Malvezzi P, O'Shaughnessy MM, Cheng XS, Cravedi P, Riella LV. A large, international study on post-transplant glomerular diseases: the TANGO project. BMC Nephrol 2018; 19:229. [PMID: 30208881 PMCID: PMC6136179 DOI: 10.1186/s12882-018-1025-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 08/28/2018] [Indexed: 12/14/2022] Open
Abstract
Background Long-term outcomes in kidney transplantation (KT) have not significantly improved during the past twenty years. Despite being a leading cause of graft failure, glomerular disease (GD) recurrence remains poorly understood, due to heterogeneity in disease pathogenesis and clinical presentation, reliance on histopathology to confirm disease recurrence, and the low incidence of individual GD subtypes. Large, international cohorts of patients with GD are urgently needed to better understand the disease pathophysiology, predictors of recurrence, and response to therapy. Methods The Post-TrANsplant GlOmerular Disease (TANGO) study is an observational, multicenter cohort study initiated in January 2017 that aims to: 1) characterize the natural history of GD after KT, 2) create a biorepository of saliva, blood, urine, stools and kidney tissue samples, and 3) establish a network of patients and centers to support novel therapeutic trials. The study includes 15 centers in America and Europe. Enrollment is open to patients with biopsy-proven GD prior to transplantation, including IgA nephropathy, membranous nephropathy, focal and segmental glomerulosclerosis, atypical hemolytic uremic syndrome, dense-deposit disease, C3 glomerulopathy, complement- and IgG-positive membranoproliferative glomerulonephritis or membranoproliferative glomerulonephritis type I-III (old classification). During phase 1, patient data will be collected in an online database. The biorepository (phase 2) will involve collection of samples from patients for identification of predictors of recurrence, biomarkers of disease activity or response to therapy, and novel pathogenic mechanisms. Finally, through phase 3, we will use our multicenter network of patients and centers to launch interventional studies. Discussion Most prior studies of post-transplant GD recurrence are single-center and retrospective, or rely upon registry data that frequently misclassify the cause of kidney disease. Systematically determining GD recurrence rates and predictors of clinical outcomes is essential to improving post-transplant outcomes. Furthermore, accurate molecular phenotyping and biomarker development will allow better understanding of individual GD pathogenesis, and potentially identify novel drug targets for GD in both native and transplanted kidneys. The TANGO study has the potential to tackle GD recurrence through a multicenter design and a comprehensive biorepository.
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Affiliation(s)
- Audrey Uffing
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02115, USA
| | - Maria José Pérez-Sáez
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02115, USA.,Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Clara Fischman
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Levy Place, New York, NY, 10029, USA
| | - Samira Farouk
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Levy Place, New York, NY, 10029, USA
| | - Roberto Ceratti Manfro
- Renal Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Andrea Carla Bauer
- Renal Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Bruno Lichtenfels
- Renal Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Juliana B Mansur
- Renal Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Hélio Tedesco-Silva
- Renal Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Gianna M Kirsztajn
- Renal Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Anna Manonelles
- Renal Division, Bellvitge University Hospital, Barcelona, Spain
| | - Oriol Bestard
- Renal Division, Bellvitge University Hospital, Barcelona, Spain
| | | | | | | | - Elias David-Neto
- Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Enver Akalin
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Omar Mohammed
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eliyahu V Khankin
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kassem Safa
- Transplant Center and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paolo Malvezzi
- Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France
| | | | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Levy Place, New York, NY, 10029, USA.
| | - Leonardo V Riella
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02115, USA.
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15
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Wang CS, Gander J, Patzer RE, Greenbaum LA. Mortality and Allograft Loss Trends Among US Pediatric Kidney Transplant Recipients With and Without Focal Segmental Glomerulosclerosis. Am J Kidney Dis 2017; 71:392-398. [PMID: 29277509 DOI: 10.1053/j.ajkd.2017.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/30/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pediatric patients with focal segmental glomerulosclerosis (FSGS) have high rates of disease recurrence and allograft failure after kidney transplantation, but there are few data for long-term survival posttransplantation. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 12,303 pediatric patients (aged <18 years), including 1,408 (11%) patients with FSGS, who received a first kidney transplant in 1990 through 2009 and were followed up through June 2015 were identified from the US Renal Data System database. PREDICTORS Primary cause of end-stage renal disease, FSGS or other. OUTCOMES All-cause patient mortality and allograft loss. RESULTS All-cause mortality significantly improved for patients with FSGS who underwent transplantation in the 2000s versus the 1990s (6.72 vs 12.24 deaths/1,000 patient-years; HR, 0.55; 95% CI, 0.39-0.78; P<0.001). Reductions in allograft loss were less dramatic (75.91 vs 89.05 events/1,000 patient-years; HR, 0.85; 95% CI, 0.74-0.98; P=0.02). After adjusting for baseline characteristics at the time of transplantation, patients with FSGS had similar rates of death compared with patients without FSGS (HRs of 0.81 [P=0.6] and 1.06 [P=0.2] among those who underwent transplantation in the 2000s and 1990s, respectively) despite higher rates of allograft loss (HRs of 1.17 [P=0.03] and 1.27 [P<0.001], respectively). Among patients who underwent transplantation in the 2000s, further adjustment for allograft failure as a time-varying covariate demonstrated a lower rate of death among patients with FSGS compared with those without FSGS (HR, 0.70; P=0.02). LIMITATIONS Lack of information about certain risk factors for mortality, including duration of chronic kidney disease; missing data; and potential primary disease misclassification. CONCLUSIONS Survival of pediatric kidney transplant recipients with FSGS improved between the 1990s and 2000s and was similar to that of recipients without FSGS. Interestingly, adjustment for allograft failure showed greater survival for pediatric patients with FSGS who underwent transplantation in the 2000s as compared with others, suggesting that effective interventions to decrease allograft loss due to disease recurrence may improve patient survival.
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Affiliation(s)
- Chia-Shi Wang
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA.
| | - Jennifer Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
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16
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Affiliation(s)
- Sandra Amaral
- Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Alicia Neu
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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